Summary Report for FSPSAs Ending During the Report Period Center: 09
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 04/01/09 and 06/30/09 Date of Report: 08-25-09 Page: 1
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 2.38 $38.76 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 2.38 $25.68 $10.80
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 2 2 1.38 $29.40 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 1.71 $102.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.00 $358.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 7.00 $388.50 $55.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 4.29 $207.86 $48.50
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Subtotal (Total Children Is Unduplicated) 16 26 27.13 $1297.93 $47.84
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 8 8.00 $12000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.44 $30.60 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 15.20 $760.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 32 34 33.97 $1698.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 40 42 40.47 $2023.34 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 28 28.00 $1400.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 61 66 66.83 $3341.67 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 21.71 $1594.26 $73.42
EIIF -COUN UNSPECIFIED COUNSELING 1 1 10.29 $514.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 327 382 1734.44 $86721.89 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 4.71 $235.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 402 474 1945.14 $132036.41 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 14.39 $781.69 $54.32
PHY -97110 PT SESSION BY LICENSED PT 352 400 1767.48 $119976.45 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 7.14 $388.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 17 17.00 $17.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 2.18 $141.39 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 9 9 14.30 $267.64 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 4 7.83 $391.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 742 843 4052.67 $275095.23 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 5 35.71 $471.43 $13.20
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Subtotal (Total Children Is Unduplicated) 1145 2339 9832.91 $640911.23 $65.18
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Total 2365 9860.04 $642209.17 $65.13
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Number of Children (Unduplicated) With at Least One Authorization 1147